Japanese Journal of Cardiovascular Surgery Vol.41, No.4

Graft Replacement of Distal Arch Aneurysm after Branched Open Stentgraft Method due to Third Time Endoleak

（Department of Cardiothoracic Surgery, Ehime University Graduate School of Medicine, Toon, Japan）

Masahiro Ryugo	Hironori Izutani	Takumi Yasugi
Mitsugi Nagashima	Toru Okamura	Fumiaki Shikata

A 71-year-old man had undergone branched open stent grafting for a distal arch aneurysm in May 2006. He subsequently developed multiple episodes of postoperative endoleak successfully treated by TEVAR in January and November 2009. He visited our hospital complaining of back pain in May 2011. Chest computed tomography showed increasing size of the aneurysm and recurrent endoleak of the distal stent graft, and impending rupture of the aneurysm was diagnosed. Considering the technical difficulty of repair by TEVAR, we performed graft replacement of the aneurysm with removal of the previous stent graft. The postoperative course was unremarkable and he was discharged on postoperative day 11.
  Jpn. J. Cardiovasc. Surg. 41:161-164（2012）

Keywords：Branched Open Stentgraft method, TEVAR, endoleak

Successful Surgical Treatment for Anterior Papillary Muscle Rupture Caused by Isolated First Diagonal Branch Occlusion

（First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan）

Kazuhiro Ohkura	Norihiko Shiiya	Katsushi Yamashita
Naoki Washiyama	Masato Suzuki	Daisuke Takahashi
Ken Yamanaka

A 62-year-old woman was admitted to a regional hospital for acute myocardial infarction. Emergency coronary angiography revealed occlusion of the first diagonal branch, and transesophageal echocardiography showed severe mitral regurgitation due to anterior papillary muscle rupture. She was transferred to our hospital in a state of cardiogenic shock despite the use of high-dose catecholamine and intra-aortic balloon pumping. We immediately performed mitral valve replacement. The patient’s postoperative course was uneventful and she was ambulatory when transferred to another hospital on foot on postoperative day 19. Physicians should be aware that fatal anterior papillary muscle rupture may be caused by isolated occlusion of the diagonal branch.
  Jpn. J. Cardiovasc. Surg. 41:165-168（2012）

Keywords：acute myocardial infarction, papillary muscle rupture, acute mitral regurgitation, first diagonal branch

A Strategy of Cardiopulmonary Bypass for a Pseudoaneurysm of Ascending Aorta after Aortic Valve Replacement

（Department of Cardiovascular Surgery, Nihonkai General Hospital, Yamagata Prefectural and Sakata Municipal Organization, Sakata, Japan）

Yoshinori Kuroda	Hideaki Uchino	Tetsurou Uchida
Atsushi Yamashita	Takao Shimanuki

A 29-year-old man with high fever and chest pain was admitted to our hospital. He had undergone aortic valve replacement 1 month before admission to our hospital. Since computed tomography revealed a pseudoaneurysm in the ascending aorta, he underwent an emergency operation. An occlusion catheter was inserted into the ascending aorta via the left femoral artery, in preparation for pseudoaneurysm rupture. Cardiopulmonary bypass was established with inflow via the right femoral artery and the right axillary artery, and with vacuum-assisted venous drainage via the right femoral vein. After core cooling, we performed resternotomy. The pseudoaneurysm ruptured while we were exfoliating the adhesion around the aorta. We inflated the occlusion catheter in the ascending aorta and controlled the bleeding. We continued core cooling and ventricular fibrillation occurred at 30℃. Subsequently, we induced circulatory arrest, and selective cerebral perfusion was initiated. We inflated the occlusion catheter in the descending aorta and initiated systemic circulation with inflow via the right femoral artery. The origin of the pseudoaneurysm was the region of cannulation in the previous operation. Therefore, we replaced the ascending aorta and performed omentopexy. In this case we reported the use of a strategy involving cardiopulmonary bypass for a pseudoaneurysm in the ascending aorta.
  Jpn. J. Cardiovasc. Surg. 41:169-172（2012）

Keywords：pseudoaneurysm of the ascending aorta, occlusion catheter, vacuum assisted venous drainage

A Case of Mycotic Aneurysm Repaired by Wrapping the Pedicled Latissimus Dorsi Muscle Flap around the Artificial Graft

（Department of Cardiovascular Surgery, Kawasaki Municipal Hospital, Kawasaki, Japan）

Shinichi Taguchi

A 69-year-old man with histories of cardiac and abdominal operations was hospitalized in another hospital due to brain contusion. Due to hemorrhage from the distal descending thoracic aorta, he was transferred to our hospital. After a diagnosis rupture of mycotic aneurysm an urgent operation was performed. The aneurysm was replaced by an in situ graft. For infection control, the graft was wrapped tightly by a pedicled latissimus dorsi muscle flap. Postoperatively, local infection of the muscle-dissected cavity continued. Although his life was ultimately not saved, he was able to live a comfortable hospital life with some activity for 8 months.
  Jpn. J. Cardiovasc. Surg. 41:173-177（2012）

Keywords：rupture of mycotic aneurysm, latissimus dorsi muscle flap, pedicled muscle flap, MRSA infection

Rupture of a Right Internal Iliac Artery Aneurysm after Coil Embolization and an Exclusion Operation

（Department of Cardiovascular Surgery, Hakodate Municipal Hospital, Hakodate, Japan）

Toshio Baba	Kiyofumi Morishita	Shunsuke Oohori
Kousuke Ujihira

The patient, a 80-year-old man, had undergone aneurysmectomy and graft replacement of the right external iliac artery aneurysm and coil embolization and exclusion of the right internal iliac artery aneurysm in 2007. Computed tomography showed a rupture of the right internal iliac artery aneurysm in 2010. We performed aneurysmectomy and occlusion of the gluteal artery. The patient had a satisfactory postoperative course.
  Jpn. J. Cardiovasc. Surg. 41:178-181（2012）

Keywords：embolization, internal iliac artery aneurysm, exclusion operation

Successful Surgical Management of a Papillary Fibroelastoma in the Left Ventricle

（Department of Cardiovascular Surgery, Otsu Municipal Hospital, Otsu, Japan, and Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine Hospital*, Kyoto, Japan）

Takahisa Okano

Katsuji Fujiwara

Hitoshi Yaku*

Papillary fibroelastoma is a rare benign cardiac tumor generally arising from the valvular endocardium. We describe the successful surgical management of a patient who had a papillary fibroelastoma attached to a false tendon of the left ventricle. A 71-year old man was admitted with a left ventricular tumor. Routine transthoracic echocardiography revealed a mobile, 6×8mm mass, which was attached to a false tendon in the apical area of the left ventricle. Continuous intravenous heparin was commenced to avoid the embolism, and then an urgent operation was performed, consisting of left ventriculotomy following establishment of a standard cardiopulmonary bypass. A mobile gelatinous mass with a short stalk, 7mm in diameter, was attached to the false tendon. The mass was excised including a part of the false tendon. The excised tumor changed its shape in saline to a sea-anemone like tumor. The histopathological findings were consistent with the diagnosis of papillary fibroelastoma. The patient made an uneventful recovery and was discharged from the hospital on postoperative day 12.
  Jpn. J. Cardiovasc. Surg. 41:182-184（2012）

Keywords：papillary fibroelastoma, left ventricular tumor, cardiac tumor

A Case of Surgical Treatment for Aortic Root Dissection after Full Aortic Root Replacement with Stentless Aortic Valve

（Department of Cardiovascular Surgery, IMS Katsushika Heart Center, Tokyo, Japan）

Nobuaki Suzuki	Tadaaki Koyama	Katsuhiro Hosoyama
Yoshinori Nakahara	Yuusuke Tsukioka	Takuya Miyazaki
Ken Furuhata	Tomohiro Iwakura	Takeyuki Kanemura
Shigehiko Yoshida

A 84-year-old woman underwent aortic root replacement with stentless bioprosthesis and coronary artery bypass grafting. Four years later, she presented with dyspnea. Transthoracic echocardiography revealed aortic regurgitation, dilation and dissection of the sinus of Valsalva. A Bentall operation was performed by using prosthetic graft and bioprosthetic valve. Intimal tear caused the aortic wall dissection and aneurysm of the Freestyle valve.
  Jpn. J. Cardiovasc. Surg. 41:185-187（2012）

Keywords：stentless aortic valve, dissecting aortic aneurysm, Bentall operation

Two Cases of Pseudoaneurysms in Multiple Anastomotic Sites Occurring after the Original Bentall and Cabrol Procedure

（Department of Cardiovascular Surgery, Osaka Medical College Hospital, Takatsuki, Japan）

Tomoyasu Sasaki	Hayato Konishi	Yoshikazu Motohashi
Hiroaki Uchida	Mari Kakita	Eiki Woo
Sachiko Kanki	Masahiro Daimon	Hideki Ozawa
Takahiro Katsumata

We report two cases of pseudoaneurysms occurring at the anastomotic sites that had to be repaired several times after the original Bentall and Cabrol procedure. Case 1. A 62-year-old man had surgery to repair pseudoaneurysms at the anastomotic sites of the distal ascending aorta and right coronary artery 22 years after undergoing the original Bentall procedure. The anastomosis of the left coronary artery was normal at the time of the operation;however, he was given a diagnosis of a pseudoaneurysm at the anastomotic site of the left coronary artery 2 years after the operation. Case 2. A 61-year-old man with Marfan syndrome underwent surgery twice to repair pseudoaneurysms at the anastomotic sites of the aortic annulus and the left coronary artery 2 and 11 years, respectively, after the original Cabrol procedure. In addition, 23 years after the Cabrol procedure, he was given a diagnosis of a pseudoaneurysm at the anastomotic site of the distal ascending aorta. Their pseudoaneurysms were successfully treated by the reanastomosis of new grafts. Computed tomography detected no recurrence of the pseudoaneurysm in the follow-up period. However, continual close observation for the recurrence of a pseudoaneurysm in the remaining anastomotic sites is necessary.
  Jpn. J. Cardiovasc. Surg. 41:188-190（2012）

Keywords：original Bentall, original Cabrol, pseudoaneurysm

Metastatic Leiomyosarcoma Causing Right Ventricular Outflow Stenosis

（Department of Cardiovascular Surgery, Nayoro City General Hospital, Nayoro, Japan）

Katsuaki Magishi

Yuichi Izumi

Noriyuki Shimizu

We report a rare case of cardiac metastases of leiomyosarcoma. A 64-year-old woman presented with chest pain. Nineteen years ago, she had undergone resection of uterine leiomyosarcoma 19 years pveviously and 9 years previously, resecting of colon metastases. Echocardiogram and computed tomogram revealed tumor in the right ventricular outflow tract, which moved into the pulmonary artery. Because obstruction of the main pulmonary artery was possible, the tumor was resected. The tumor was leiomyosarcoma, which suggested metastasis from the uterine tumor. No recurrence of the tumor was seen 9 months after surgery despite lack of any treatment.
  Jpn. J. Cardiovasc. Surg. 41:191-194（2012）

Keywords：metastatic cardiac tumor, cardiac sarcoma, uterus, leiomyosarcoma, right ventricular outflow tract stenosis

A Case of Aortopulmonary Artery Fistula

（Department of Cardiovascular Surgery, Shizuoka City Hospital, Shizuoka, Japan）

Tatsuji Okada	Masanao Nakai	Mitsuomi Shimamoto
Fumio Yamazaki	Yujiro Miura	Tatsuya Itonaga
Ryota Nomura	Yasuhiko Terai	Yuta Miyano
Yoshisuke Murata

Acute aortopulmonary artery fistula is a rare but potentially fatal disorder. We encountered a case in which this disorder was successfully treated by urgent total arch graft replacement and repair of the left pulmonary artery. A 74-year-old man was referred to Shizuoka City Hospital with a 2-day history of worsening dyspnea and thoracic aortic aneurysm. The patient had a history of hypertension and dyslipidemia. Physical examination showed diastolic hypotension, marked peripheral coldness, and systolic murmur. Arterial blood gas analysis showed severe metabolic acidosis with base excess of －16mmol/l. Contrast-enhanced computed tomography（CT）revealed an aortic arch aneurysm on the lesser curvature, almost obstructing the left pulmonary artery. A Swan-Ganz catheter study confirmed severe low-output syndrome and uncompensated congestive heart failure. After amelioration of critically ill conditions with dopamine, milrinone, and carperitide, oxymetry revealed significant left-to-right shunt with Qp/Qs＝3.2 at the pulmonary artery level. Acute aortopulmonary artery fistula was diagnosed and urgent surgery was planned. Transesophageal echocardiography showed systolic shunt flow from the aneurysm into the left pulmonary artery. Surgery was performed through a median sternotomy. Aortic arch graft replacement with a 24-mm Dacron graft and repair of the left pulmonary artery with an equine pericardial patch were accomplished under hypothermic circulatory arrest and selective antegrade cerebral perfusion. Flooding of pulmonary circulation until circulatory arrest was prevented by manual control through the main pulmonary artery incision. Postoperative recovery was uneventful, and the patient is doing well at one year postoperatively.
  Jpn. J. Cardiovasc. Surg. 41:195-199（2012）

Keywords：aortic arch aneurysm, pulmonary artery, rupture, total arch replacement

Reconstruction of the Left Ventricular Outflow Tract with a Rolled Equine Pericardium for Annular Abscess after Aortic Root Replacement

（Department of Surgery, Kurume University Hospital, Kurume, Japan）

Yuichiro Hirata	Shuji Fukunaga	Tomokazu Kosuga
Hiroyuki Saisyo	Kumiko Wada	Ryusuke Mori
Hidetoshi Akashi	Shigeaki Aoyagi

A 61 year-old man was admitted with fever and chest discomfort. He had undergone aortic root replacement for annuloaortic ectasia at age 57. Computed tomography showed a pseudoaneurysm and an abscess formation around the aortic root. Prosthetic valve endocarditis was diagnosed and the underwent repeat aortic root replacement. After debridement and irrigation of the abscess cavity, the left ventricular outflow tract was reconstructed with an equine pericardium, which was rolled to form a conduit. The pericardial conduit was securely sutured to the healthy left ventricular wall and the mitral annulus. A 25mm-Freestyle valve was then sutured to the distal end of the conduit. The previous prosthetic vascular graft was removed and Completely replaced with a new prosthesis. This method provided secure fixation of a new prosthetic valved conduit to the normal left ventricular tissue with an excellent operative visual field.
  Jpn. J. Cardiovasc. Surg. 41:200-203（2012）

Keywords：aortic root replacement, prosthetic valve endocarditis, annular abscess, left ventricular outflow tract reconstruction, equine pericardium

A Case of Vasculo-Behçet Disease Diagnosed by Right Atrial Mass and Inferior Vena Cava Thrombosis

（Department of Cardiovascular Surgery, Social Insurance Kinan Hospital, Izumisano, Japan）

Ryohei Matsuura	Nobuo Sakagoshi	Kenta Masada
Yasuhisa Shimazaki

We report a rare case of 16-year-old boy who was given a diagnosis vasculo-Behçet disease after removing a right atrial thrombus. He was admitted to our hospital with abdominal pain and fever. He was underwent appendectomy for suspected appendicitis, but the appendix was normal. Additional image examinations revealed a mobile right atrial mass and inferior vena cava thrombosis, and the patient was sent to reoperation urgently to prevent pulmonary embolism. Surgery revealed the mass to be a thrombus. Vasculo-Behçet disease was diagnosed based on the patient’s history and examination data. He was discharged on the 17th postoperative day. Cardiac mass excision should be immediately considered in such cases, and the differential diagnosis of Behçet disease was important for this case.
  Jpn. J. Cardiovasc. Surg. 41:204-206（2012）

Keywords：right atrial mass, vasculo-Behçet disease

Refractory Perioperative Hypotension in Off-Pump Coronary Artery Bypass Grafting in a Patient with Schizophrenia

（Department of Cardiovascular Surgery, Maizuru Mutual Hospital, Maizuru, Japan）

Suguru Ohira

Tsutomu Matsushita

Shinsuke Masuda

A 57 year-old man with angina pectoris was transferred to our hospital for coronary artery bypass grafting. His past history was schizophrenia and paroxysmal atrial fibrillation. He had been taking major tranquilizers for 20 years. Off-pump coronary artery bypass grafting（RITA-LAD, LITA-OM-D2, Ao-SVG-#4PD-#14PL）and bilateral pulmonary vein isolation was performed. During the distal anastomosis, systolic blood pressure was decreased and bolus infusion of norepinephrine and phenylephrine were not effective. Vasopressin was injected（1U/shot), and stabilized his hemodynamic status without any mechanical support. After the operation, vasopressin was continued to postoperative day（POD）4. There was no side effect related to vasopressin. He was discharged from the hospital on POD 12. When major tranquilizers are taken for a long time patients can be resistant, or overreact to catecholamine. Vasopressin can be a valid option as a vasopressor for such catecholamine refractory hypotension.
  Jpn. J. Cardiovasc. Surg. 41:207-210（2012）

Keywords：schizophrenia, coronary artery bypass grafting, vasopressin

Disruption of a Dacron Graft Caused by the Vertebral Body of the Lumbar Vertebrae after Reconstruction of the Thoracoabdominal Aortic Aneurysm

（Department of Cardiovascular Surgery, Nakagami Hospital, Okinawa, Japan, and Department of Cardiovascular Surgery, Nippon Medical School Musashikosugi Hospital*, Tokyo, Japan）

Kouan Orii	Masafumi Hioki*	Yoshio Iedokoro*
Jiro Honda

We report an extremely rare case of early disruption of a woven Dacron graft by the mechanical force of the lumbar vertebral body after a thoracoabdominal aortic aneurysm repair. A 75-year-old man with thoracoabdominal aortic aneurysm of Crawford type III underwent replacement of the thoracoabdominal aorta using a Gelweave thoracoabdominal graft（Vascutek）and a Gelweave bifurcate graft（Vascutek). His postoperative course was uneventful and discharged on postoperative day 20. On the 22nd postoperative day, he was re-hospitalized with low back pain. Computed tomography scanning showed a massive hematoma around the region of the graft-to-graft anastomosis. He underwent an emergency operation. At laparotomy, the Gelweave thoracoabdominal graft had a 2-mm hole which had been caused by the mechanical force of lumbar vertebral body, which was not related to the anastomosis. The graft was repaired with a 4-0 polypropylene buttress suture and a new prosthesis graft was used to wrap around the disrupted graft.
  Jpn. J. Cardiovasc. Surg. 41:211-214（2012）

Keywords：thoracoabdominal aortic aneurysm, lumbar vertebral body of vertebrae, osteophyte, disruption of dacron graft

Axillo-Bifemoral Artery Bypass for Atypical Coarctation in an Elderly Patient with Hypertensive Heart Failure

（Department of Thoracic Cardiovascular Surgery, Showa University, Tokyo, Japan）

Kazuto Maruta	Hiromasa Kawaura	Hiroyuki Iizuka
Masaomi Fukuzumi	Noboru Ishikawa	Tadashi Omoto
Takeo Tedoriya

A 81-year old woman had hypertensive heart failure. She had a history of intermittent claudication for 5 years. Her ankle brachial pressure index（ABI）was 0.53 on the right and 0.58 on the left side. Coarctation of the descending aorta with severe calcification was found by a whole body CT. After medical therapy for heart failure, axillo-bifemoral artery bypass using an 8mm ringed expanded polytetrafluoroethylene（ePTFE）graft was performed. Postoperatively, ABI improved to 0.83 on the right and 0.87 on the left side. The patient is doing well without any signs of heart failure or intermittent claudication. Although it is a palliative operation, axillo-bifemoral artery bypass is an effective and less-invasive procedure and appropriate for elderly patients.
  Jpn. J. Cardiovasc. Surg. 41:215-218（2012）

Keywords：atypical coarctation, extra anatomical bypass, axillo-bifemoral artery bypass, hypertensive heart failure, elderly patient